Posted
by
michael
on Tuesday October 05, 2004 @02:35PM
from the all-the-king's-horses-and-all-the-king's-men dept.

cradle writes "On September 6th, the $239 Million Dollar NOAA N-Prime Satellite toppled over and crashed to the floor of Lockheed Martin Space Systems' factory in Sunnyvale, CA, as it was being repositioned to replace an instrument. Today NASA released their report on the cause of the accident. It seems somebody forgot to check whether it was bolted down: '... during an operation that required repositioning (rotating) the
TIROS NOAA N-PRIME spacecraft from a vertical to a horizontal position, the spacecraft
slipped from the Turn-Over Cart (TOC) and fell to the floor. The spacecraft fell because the
TIROS adapter plate to which it was mounted was not bolted to the TOC adapter plate with the
required 24 bolts. The bolts were removed from the TOC by another project while the cart was
in a common staging area, an activity which was not communicated to the NOAA project team.'"

Yeah that sucks but these things happen. Whether you're working on a 100K toy or a $300 million dollar one, every once and awhile there's going to be a mishap.
Still, it sounds like there's a management problem here if people are going around removing bolts and the project team isn't even aware of it. If there's literally so few nuts and bolts handy for the various projects going on that they feel the need to cannabalize other projects, that's a disaster waiting to happen.
I hope my neighbour doesn't decide to remove my brakes without letting me know.

If I was "repositioning" a $239,000,000.00 piece of hardware, I would visually check the bolts before starting the rotation. I would also check every other piece of safety equipment... twice. If the bolts were there, I would probably check the torque on them, if I hadn't tightened them myself.

Jeeeez, people, this isn't rocket science. Well actually it is rocket science, but that's the difference between rocket science and stuff that blows up on the pad.

So, do you visually check the lug nuts on your car everyday before you drive off? How about after leaving it unattended in an airport parking lot for a couple of days? No? Well, that's the difference between being a driver and being an oozing pile of red goo on the highway...

I think the transition for sentient being to red goo is much more motivating than the loss of a few dollars in hardware. That's just me though... YMMV

>You say that now, but once you start working with that type of equipment every day, you get lazy.

Familiar -> Complacent -> Lazy -> Dead

>They had used the TOC a few days prior, and there was no documentation that the bolts had been removed, so they assumed that it was fine. If some that other project team hadn't forgotten the documentation this wouldnt've happened.

[Fred] OK Bob, let's run through the checklist and fire this 747 up.

[Bob] Don't bother with the checklist. Some guys flew it back from Tokyo a couple of days ago. Everything should still work, and I don't see any trouble tickets. They probably fueled it up, too.

If this was something like a burned out computer, a bolt shearing off, or the machine it was supposed to be bolted to failing and dumping the satellite on the ground, I'd agree with you. There are some things that just happen, even though every reasonable analysis says they won't.

However, there are still some things that shouldn't go wrong, ever, and there's not an excuse for it after the fact. This is one of them. You don't pull parts off something that's supposed to work without replacing them. This is almost akin to a mechanic servicing your engine and having "extra" parts left over when he closes the hood again. They were there for a reason, and they need to go back on before you finish whatever you're doing.

I agree with you, but good process doesn't bore me at all. But I know I'm the exception. The truth is Managagment just wants to get the job done with the least resources, so they pressure the techs with increasing workload and tend to look the other way when people cut corners to get the job done. Techs know they are supposed to do process 100%, but they don't want to be the guy who takes twice as long to do stuff because of following procss. So whenever I see major screw ups like this, I blame management and ops equally.

Engineers, BTW, write processes but never follow their own process. Thus, they leave messes for the techs to sort out.

Well yeah, but I also don't expect the guy in the next parking space to 'borrow' the lug nuts for any reason and I sure as hell hope that if he did, he'd leave a note on the windshield so I know about it before I drive away!